Safety and Efficiency of a Chest Pain Diagnostic Algorithm With Selective Outpatient Stress Testing for Emergency Department Patients With Potential Ischemic Chest Pain.

Ann Emerg Med. 2012 Jan 4;

Authors: Scheuermeyer FX, Innes G, Grafstein E, Kiess M, Boychuk B, Yu E, Kalla D, Christenson J

Abstract
STUDY OBJECTIVE: Chest pain units have been used to monitor and investigate emergency department (ED) patients with potential ischemic chest pain to reduce the possibility of missed acute coronary syndrome. We seek to optimize the use of hospital resources by implementing a chest pain diagnostic algorithm. METHODS: This was a prospective cohort study of ED patients with potential ischemic chest pain. High-risk patients were referred to cardiology, and patients without ECG or biomarker evidence of ischemia were discharged home after 2 to 6 hours of observation. Emergency physicians scheduled discharged patients for outpatient stress ECGs or radionuclide scans at the hospital within 48 hours. Patients with positive provocative test results were immediately referred back to the ED. The primary outcome was the rate of missed diagnosis of acute coronary syndrome at 30 days. RESULTS: We prospectively followed 1,116 consecutive patients who went through the chest pain diagnostic algorithm, of whom 197 (17.7%) were admitted at the index visit and 254 (22.8%) received outpatient testing on discharge. The 30-day acute coronary syndrome event rate was 10.8%, and the 30-day missed acute coronary syndrome rate was 0% (95% confidence interval 0% to 2.4%). Of the 120 acute coronary syndrome cases, 99 (82.5%) were diagnosed at the index ED visit, and 21 patients (17.5%) received the diagnosis during outpatient stress testing. CONCLUSION: In ED patients with chest pain, a structured diagnostic approach with time-focused ED decision points, brief observation, and selective application of early outpatient provocative testing appears both safe and diagnostically efficient, even though some patients with acute coronary syndrome may be discharged for outpatient stress testing on the index ED visit.

PMID: 22221842 [PubMed - as supplied by publisher]

Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis.

Ann Emerg Med. 2011 Dec 14;

Authors: Singh B, Parsaik AK, Agarwal D, Surana A, Mascarenhas SS, Chandra S

Abstract
STUDY OBJECTIVE: To perform a systematic review and meta-analysis to define the diagnostic performance of pulmonary embolism rule-out criteria (PERC) in deferring the need for D-dimer testing to rule out pulmonary embolism in the emergency department (ED). METHODS: We searched EMBASE, MEDLINE, Scopus, Web of Knowledge, and all the evidence-based medicine reviews that included the Cochrane Database of Systematic Reviews through August 14, 2011, and hand searched references in potentially eligible articles and conference proceedings of major emergency medicine organizations for the previous 2 years. We selected studies that reported diagnostic performance of PERC, reported original research, and were conducted in the ED, with no language restrictions. Two investigators independently identified eligible studies and extracted data. We used contingency tables to calculate sensitivity, specificity, and likelihood ratios. RESULTS: We found 12 qualifying cohorts (studying 13,885 patients with 1,391 pulmonary embolism diagnoses), 10 prospective and 2 retrospective, from 6 countries. Pooled sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios for 10 included studies were 0.97 (95% confidence interval [CI] 0.96 to 0.98), 0.23 (95% CI 0.22 to 0.24), 1.24 (95% CI 1.18 to 1.30), and 0.17 (95% CI 0.13 to 0.23), respectively. Significant heterogeneity was observed in specificity (I(2)=97.2%) and positive likelihood ratio (I(2)=84.2%). CONCLUSION: The existing literature suggests consistently high sensitivity and low but acceptable specificity of the PERC to rule out pulmonary embolism in patients with low pretest probability.

PMID: 22177109 [PubMed - as supplied by publisher]

Sublingual Buprenorphine in Acute Pain Management: A Double-Blind Randomized Clinical Trial.

Ann Emerg Med. 2011 Nov 23;

Authors: Jalili M, Fathi M, Moradi-Lakeh M, Zehtabchi S

Abstract
STUDY OBJECTIVE: We compare the efficacy and safety of sublingual buprenorphine versus intravenous morphine sulfate in emergency department adults with acute bone fracture. METHODS: Enrolled patients received buprenorphine 0.4 mg sublingually or morphine 5 mg intravenously in this double-blind, double-dummy, randomized controlled trial. Patients graded their pain with a standard 11-point numeric rating scale before medication administration and 30 and 60 minutes after, and we recorded adverse reactions. RESULTS: We analyzed 44 and 45 patients in the buprenorphine and morphine groups, respectively. Mean pain scores were similar at 30 minutes (5.0 versus 5.0; difference 0; 95% confidence interval -0.6 to 0.8) and at 60 minutes (2.2 versus 2.2; difference 0; 95% confidence interval -0.3 to 0.3). Adverse effects observed within 30 minutes were nausea (14% versus 12%), dizziness (14% versus 22%), and hypotension (4% versus 18%). CONCLUSION: For adults with acute fractures, buprenorphine 0.4 mg sublingually is as effective and safe as morphine 5 mg intravenously.

PMID: 22115823 [PubMed - as supplied by publisher]

Older US Emergency Department Patients Are Less Likely to Receive Pain Medication Than Younger Patients: Results From a National Survey.

Ann Emerg Med. 2011 Oct 25;

Authors: Platts-Mills TF, Esserman DA, Brown DL, Bortsov AV, Sloane PD, McLean SA

Abstract
STUDY OBJECTIVE: The purpose of this study is to determine whether older adults presenting to the emergency department (ED) with pain are less likely to receive pain medication than younger adults. METHODS: Pain-related visits to US EDs were identified with reason-for-visit codes from 7 years (2003 to 2009) of the National Hospital Ambulatory Medical Care Survey. The primary outcome was the administration of an analgesic. The percentage of patients receiving analgesics in 4 age groups was adjusted for measured covariates, including pain severity. RESULTS: Pain-related visits accounted for 88,031 (46.9%) ED visits by patients aged 18 years or older during the 7-year period. There were 7,585 pain-related ED visits by patients aged 75 years or older, representing an estimated 3.65 million US ED visits annually. In comparing survey-weighted unadjusted estimates, pain-related visits by patients aged 75 years or older were less likely than visits by patients aged 35 to 54 years to result in administration of an analgesic (49% versus 68.3%) or an opioid (34.8% versus 49.3%). Absolute differences in rates of analgesic and opioid administration persisted after adjustment for sex, race/ethnicity, pain severity, and other factors and multiple imputation of missing pain severity data, with visits by patients aged 75 years and older being 19.6% (95% confidence interval 17.8% to 21.4%) less likely than visits by patients aged 35 to 54 years to receive an analgesic and 14.6% (95% confidence interval 12.8% to 16.4%) less likely to receive an opioid. CONCLUSION: Patients aged 75 years and older with pain-related ED visits are less likely to receive pain medication than patients aged 35 to 54 years.

PMID: 22032803 [PubMed - as supplied by publisher]

Vital signs: central line-associated blood stream infections-United States, 2001, 2008, and 2009.

Ann Emerg Med. 2011 Nov;58(5):447-50

Authors:

Abstract
BACKGROUND: Health care-associated infections (HAIs) affect 5% of patients hospitalized in the United States each year. Central line-associated bloodstream infections (CLABSIs) are important and deadly HAIs, with reported mortality of 12% to 25%. This article provides national estimates of the number of CLABSIs among patients in ICUs, inpatient wards, and outpatient hemodialysis facilities in 2008 and 2009 and compares ICU estimates with 2001 data.
METHODS: To estimate the total number of CLABSIs among patients aged 1 year or older in the United States, Centers for Disease Control and Prevention (CDC) multiplied central line use and CLABSI rates by estimates of the total number of patient-days in each of 3 settings: ICUs, inpatient wards, and outpatient hemodialysis facilities. CDC identified total inpatient-days from the Healthcare Cost and Utilization Project's National Inpatient Sample and from the Hospital Cost Report Information System. Central line use and CLABSI rates were obtained from the National Nosocomial Infections Surveillance System for 2001 estimates (ICUs only) and from the National Healthcare Safety Network for 2009 estimates (ICUs and inpatient wards). CDC estimated the total number of outpatient hemodialysis patient-days in 2008 by using the single-day number of maintenance hemodialysis patients from the US Renal Data System. Outpatient hemodialysis central line use was obtained from the Fistula First Breakthrough Initiative, and hemodialysis CLABSI rates were estimated from the National Healthcare Safety Network. Annual pathogen-specific CLABSI rates were calculated for 2001 to 2009.
RESULTS: In 2001, an estimated 43,000 CLABSIs occurred among patients hospitalized in ICUs in the United States. In 2009, the estimated number of ICU CLABSIs had decreased to 18,000. Reductions in CLABSIs caused by Staphylococcus aureus were more marked than reductions in infections caused by Gram-negative rods, Candida spp, and Enterococcus spp. In 2009, an estimated 23,000 CLABSIs occurred among patients in inpatient wards, and in 2008, an estimated 37,000 CLABSIs occurred among patients receiving outpatient hemodialysis.
CONCLUSION: In 2009 alone, an estimated 25,000 fewer CLABSIs occurred in US ICUs than in 2001, a 58% reduction. This represents up to 6,000 lives saved and $414 million in potential excess health care costs in 2009 and approximately $1.8 billion in cumulative excess health care costs since 2001. A substantial number of CLABSIs continue to occur, especially in outpatient hemodialysis centers and inpatient wards. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Major reductions have occurred in the burden of CLABSIs in ICUs. State and federal efforts coordinated and supported by CDC, the Agency for Healthcare Research and Quality, and the Centers for Medicare & Medicaid Services and implemented by numerous health care providers likely have helped drive these reductions. The substantial number of infections occurring in non-ICU settings, especially in outpatient hemodialysis centers, and the smaller decreases in non-S aureus CLABSIs reveal important areas for expanded prevention efforts. Continued success in CLABSI prevention will require increased adherence to current CLABSI prevention recommendations, development and implementation of additional prevention strategies, and the ongoing collection and analysis of data, including specific microbiologic information. To prevent CLABSIs in hemodialysis patients, efforts to reduce central line use for hemodialysis and improve the maintenance of central lines should be expanded. The model of federal, state, facility, and health care provider collaboration that has proven so successful in CLABSI prevention should be applied to other HAIs and other health care-associated conditions.

PMID: 22018400 [PubMed - in process]

Hospital Admission Decision for Patients With Community-Acquired Pneumonia: Variability Among Physicians in an Emergency Department.

Ann Emerg Med. 2011 Sep 8;

Authors: Dean NC, Jones JP, Aronsky D, Brown S, Vines CG, Jones BE, Allen T

Abstract
STUDY OBJECTIVE: We examine variability among emergency physicians in rate of hospitalization for patients with pneumonia and the effect of variability on clinical outcomes. METHODS: We studied 2,069 LDS Hospital emergency department (ED) patients with community-acquired pneumonia who were aged 18 years or older during 1996 to 2006, identified by International Classification of Diseases, Ninth Revision coding and compatible chest radiographs. We extracted vital signs, laboratory and radiographic results, hospitalization, and outcomes from the electronic medical record. We defined "low severity" as PaO(2)/FiO(2) ratio greater than or equal to 280 mm Hg, predicted mortality less than 5% by an electronic version of CURB-65 that uses continuous and weighted elements (eCURB), and less than 3 Infectious Disease Society of America-American Thoracic Society 2007 severe pneumonia minor criteria. We adjusted hospitalization decisions and outcomes for illness severity and patient demographics. RESULTS: Initial hospitalization rate was 58%; 10.7% of patients initially treated as outpatients were secondarily hospitalized within 7 days. Median age of admitted patients was 63 years; median eCURB predicted mortality was 2.65% (mean 6.8%) versus 46 years and 0.93% for outpatients. The 18 emergency physicians (average age 44.9 [standard deviation 7.6] years; years in practice 8.4 [standard deviation 6.9]) objectively calculated and documented illness severity in 2.7% of patients. Observed 30-day mortality for inpatients was 6.8% (outpatient mortality 0.34%) and decreased over time. Individual physician admission rates ranged from 38% to 79%, with variability not explained by illness severity, time of day, day of week, resident care in conjunction with an attending physician, or patient or physician demographics. Higher hospitalization rates were not associated with reduced mortality or fewer secondary hospital admissions. CONCLUSION: We observed a 2-fold difference in pneumonia hospitalization rates among emergency physicians, unexplained by objective data.

PMID: 21907451 [PubMed - as supplied by publisher]

Adolescents and Young Adults Presenting to the Emergency Department Intoxicated From a Caffeinated Alcoholic Beverage: A Case Series.

Ann Emerg Med. 2011 Aug 3;

Authors: Cleary K, Levine DA, Hoffman RS

We describe a case series of emergency department (ED) visits for intoxication related to the use of the caffeinated alcoholic beverage Four Loko. Medical records from the 4-month period July to November 2010 were hand searched for key words such as "intoxicated," "caffeinated," "Four Loko," "alcohol," and "EtOH." Patients were included if they were younger than 25 years. Eleven cases were included. Eight (72.7%) patients presented during October 2010. The median age was 16.4 years; 90.9% were under the legal drinking age of 21 years. Seven (63.6 %) were male patients. All arrived by emergency medical services (EMS). Four patients (36.3%) were found in high-risk settings, with altered mental status on subway tracks, in public buildings, or parks after dark. Two patients had blood alcohol concentrations greater than 200 mg/dL. Six patients (54.5%) had emesis. Two patients (18.2%) were admitted to hospital, 1 each because of seizures and persistent tachycardia. Patients intoxicated with Four Loko were younger than the legal drinking age, found in high-risk situations, and often admitted to the hospital. Many of these patients used EMS and resources in the ED for alleviation of adverse effects of Four Loko.

PMID: 21820210 [PubMed - as supplied by publisher]

Qualitative Analysis of Effective Lecture Strategies in Emergency Medicine.

Ann Emerg Med. 2011 Aug 3;

Authors: Kessler CS, Dharmapuri S, Marcolini E

STUDY OBJECTIVE: We empirically identify those aspects that make an effective lecture according to both quantitative and qualitative assessments of the opinions of a select group of emergency medicine educators. METHODS: The authors worked collaboratively with the Educational Meetings Committee of the American College of Emergency Physicians (ACEP) to distribute surveys to 150 participants identified as exemplary lecturers in emergency medicine. These participants had been rated in the top 10% of all lecturers by ACEP's Educational Meetings Committee, according to audience evaluations. Respondents quantitatively rated the importance of a set of strategies for the design/organization and delivery of a lecture. Additional qualitative responses were elicited from semistructured, open-ended questions that were used to identify conceptual themes and subcategories of major themes. RESULTS: One hundred fifty surveys were sent. Seventy-four (49%) of the surveys were returned, of which 67 (45%) were analyzed. Quantitative results revealed the top 3 categories of importance about design/organization (having a manageable scope of content for the allotted time, having clear objectives, and using case-based scenarios) and the top 3 categories of importance about delivery (knowledge of slides/material, having passion/enthusiasm, and interaction with the audience). Qualitative results revealed 5 thematic concepts from the analysis of 281 statements: delivery, vehicle, content, preparation, and uncontrollables, in order of descending importance according to our results. Under the category "delivery," the subcategory "engaging" was the most frequently endorsed quality. "Relevance," under the category "content," was the second most endorsed quality of all the statements obtained. CONCLUSION: Quantitative and qualitative findings indicate that a specific and directed structure, a lecturer's knowledge base, and confidence and enthusiasm for the material are key components in the development of an effective lecture. These self-reported findings help describe strategies of exemplary emergency medicine lecturers that can be considered by faculty, residents, and other presenters.

PMID: 21820211 [PubMed - as supplied by publisher]

Diabetes Is Not Associated With Increased Mortality in Emergency Department Patients With Sepsis.

Ann Emerg Med. 2011 Jun 15;

Authors: Schuetz P, Jones AE, Howell MD, Trzeciak S, Ngo L, Younger JG, Aird W, Shapiro NI

STUDY OBJECTIVE: Despite its high prevalence, the influence of diabetes on outcomes of emergency department (ED) patients with sepsis remains undefined. Our aim is to investigate the association of diabetes and initial glucose level with mortality in patients with suspected infection from the ED. METHODS: Three independent, observational, prospective cohorts from 2 large US tertiary care centers were studied. We included patients admitted to the hospital from the ED with suspected infection. We investigated the association of diabetes and inhospital mortality within each cohort separately and then overall with logistic regression and generalized estimating equations adjusted for age, sex, disease severity, and sepsis syndrome. We also tested for an interaction between diabetes and hyperglycemia/hypoglycemia. RESULTS: A total of 7,754 patients were included. The mortality rate was 4.3% (95% confidence interval [CI] 3.9% to 4.8%) and similar in diabetic and nondiabetic patients (4.1% versus 4.4%; absolute risk difference 0.4%; 95% CI -0.7% to 1.4%). There was no significant association between diabetes and mortality in adjusted analysis (odds ratio [OR] overall 0.85; 95% CI 0.71 to 1.01). Diabetes significantly modified the effect of hyperglycemia and hypoglycemia with mortality; initial glucose levels greater than 200 mg/dL were associated with higher mortality in nondiabetic patients (OR 2.1; 95% CI 1.4 to 3.0) but not in diabetic patients (OR 1.0; 95% CI 0.2 to 4.7), whereas glucose levels less than 100 mg/dL were associated with higher mortality mainly in the diabetic population (OR 2.3; 95% CI 1.6 to 3.3) and to a lesser extent in nondiabetic patients (OR 1.1; 95% CI 1.03 to 1.14). CONCLUSION: We found no evidence for a harmful association of diabetes and mortality in patients across different sepsis severities. High initial glucose levels were associated with adverse outcomes in the nondiabetic population only. Further investigation is warranted to determine the mechanism for these effects.

PMID: 21683473 [PubMed - as supplied by publisher]

Rethinking testing for pulmonary embolism: less is more.

Ann Emerg Med. 2011 Jun;57(6):622-627.e3

Authors: Newman DH, Schriger DL

PMID: 21621091 [PubMed - in process]

Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism.

Ann Emerg Med. 2011 Jun;57(6):628-652.e75

Authors: Fesmire FM, Brown MD, Espinosa JA, Shih RD, Silvers SM, Wolf SJ, Decker WW

PMID: 21621092 [PubMed - in process]

The Financial Consequences of Lost Demand and Reducing Boarding in Hospital Emergency Departments.

Ann Emerg Med. 2011 Apr 20;

Authors: Pines JM, Batt RJ, Hilton JA, Terwiesch C

STUDY OBJECTIVE: Some have suggested that emergency department (ED) boarding is prevalent because it maximizes revenue as hospitals prioritize non-ED admissions, which reimburse higher than ED admissions. We explore the revenue implications to the overall hospital of reducing boarding in the ED. METHODS: We quantified the revenue effect of reducing boarding-the balance of higher ED demand and the reduction of non-ED admissions-using financial modeling informed by regression analysis and discrete-event simulation with data from 1 inner-city teaching hospital during 2 years (118,000 ED visits, 22% ED admission rate, 7% left without being seen rate, 36,000 non-ED admissions). Various inpatient bed management policies for reducing non-ED admissions were tested. RESULTS: Non-ED admissions generated more revenue than ED admissions ($4,118 versus $2,268 per inpatient day). A 1-hour reduction in ED boarding time would result in $9,693 to $13,298 of additional daily revenue from capturing left without being seen and diverted ambulance patients. To accommodate this demand, we found that simulated management policies in which non-ED admissions are reduced without consideration to hospital capacity (ie, static policies) mostly did not result in higher revenue. Many dynamic policies requiring cancellation of various proportions of non-ED admissions when the hospital reaches specific trigger points increased revenue. The optimal strategies tested resulted in an estimated $2.7 million and $3.6 in net revenue per year, depending on whether left without being seen patients were assumed to be outpatients or mirrored ambulatory admission rates, respectively. CONCLUSION: Dynamic inpatient bed management in inner-city teaching hospitals in which non-ED admissions are occasionally reduced to ensure that EDs have reduced boarding times is a financially attractive strategy.

PMID: 21514004 [PubMed - as supplied by publisher]

Emergency Department Management of Patients on Warfarin Therapy.

Ann Emerg Med. 2011 Apr 7;

Authors: Meeker E, Dennehy CE, Weber EJ, Kayser SR

STUDY OBJECTIVE: To characterize warfarin management in the emergency department (ED). METHODS: This was a retrospective, cross-sectional, observational study of patients who were receiving warfarin and were discharged from a tertiary care, academic urban ED between June and August 2007. We abstracted patient demographics, presenting complaint, international normalized ratio (INR) if tested, indication for warfarin if documented, new medications administered or prescribed in the ED, and discharge instructions. Presenting complaints were categorized according to whether they were warfarin-related and concerning for thrombosis or bleeding. The primary outcome measure was the prevalence of warfarin therapy. The secondary outcome measures were frequency with which ED providers obtained an INR result, response to nontherapeutic results, administration or prescription of interacting medications, and percentage of patients receiving recommendations for anticoagulation follow-up. RESULTS: Two percent (111/7,195) of all patients presenting to and discharged from the ED during the study period were found to be receiving warfarin. Seventy-one percent (79/111) had an INR checked. Nontherapeutic INRs were recorded for 49% (39/79) of patients; ED providers intervened to address these results in 21% (8/39) of cases. Seventy-one percent (5/7) of patients with a supratherapeutic INR received an intervention compared with 9% (3/32) of patients with a subtherapeutic INR. Seventeen percent (19/111) and 13% (14/111) of patients received or were prescribed potentially interacting medications, respectively. Recommendations for specific anticoagulation follow-up were documented for 19% (21/111) of all patients. CONCLUSION: Patients receiving warfarin frequently present to the ED and often have nontherapeutic INRs. Potential areas for improvement in ED management include greater attention to subtherapeutic INRs, interacting medications, and discharge planning.

PMID: 21481971 [PubMed - as supplied by publisher]

Two Days of Dexamethasone Versus 5 Days of Prednisone in the Treatment of Acute Asthma: A Randomized Controlled Trial.

Ann Emerg Med. 2011 Feb 17;

Authors: Kravitz J, Dominici P, Ufberg J, Fisher J, Giraldo P

STUDY OBJECTIVE: Dexamethasone has a longer half-life than prednisone and is well tolerated orally. We compare the time needed to return to normal activity and the frequency of relapse after acute exacerbation in adults receiving either 5 days of prednisone or 2 days of dexamethasone. METHODS: We randomized adult emergency department patients (aged 18 to 45 years) with acute exacerbations of asthma (peak expiratory flow rate less than 80% of ideal) to receive either 50 mg of daily oral prednisone for 5 days or 16 mg of daily oral dexamethasone for 2 days. Outcomes were assessed by telephone follow-up. RESULTS: Ninety-six prednisone and 104 dexamethasone subjects completed the study regimen and follow-up. More patients in the dexamethasone group reported a return to normal activities within 3 days compared with the prednisone group (90% versus 80%; difference 10%; 95% confidence interval 0% to 20%; P=.049). Relapse was similar between groups (13% versus 11%; difference 2%; 95% confidence interval -7% to 11%, P=.67). CONCLUSION: In acute exacerbations of asthma in adults, 2 days of oral dexamethasone is at least as effective as 5 days of oral prednisone in returning patients to their normal level of activity and preventing relapse.

PMID: 21334098 [PubMed - as supplied by publisher]

Hospital Determinants of Emergency Department Left Without Being Seen Rates.

Ann Emerg Med. 2011 Feb 18;

Authors: Hsia RY, Asch SM, Weiss RE, Zingmond D, Liang LJ, Han W, McCreath H, Sun BC

STUDY OBJECTIVE: The proportion of patients who leave without being seen in the emergency department (ED) is an outcome-oriented measure of impaired access to emergency care and represents the failure of an emergency care delivery system to meet its goals of providing care to those most in need. Little is known about variation in the amount of left without being seen or about hospital-level determinants. Such knowledge is necessary to target hospital-level interventions to improve access to emergency care. We seek to determine whether hospital-level socioeconomic status case mix or hospital structural characteristics are predictive of ED left without being seen rates. METHODS: We performed a cross-sectional study of all acute-care, nonfederal hospitals in California that operated an ED in 2007, using data from the California Office of Statewide Health Planning and Development database and the US census. Our outcome of interest was whether a visit to a given hospital ED resulted in left without being seen. The proportion of left without being seen was measured by the number of left without being seen cases out of the total number of visits. RESULTS: We studied 9.2 million ED visits to 262 hospitals in California. The percentage of left without being seen varied greatly over hospitals, ranging from 0% to 20.3%, with a median percentage of 2.6%. In multivariable analyses adjusting for hospital-level socioeconomic status case mix, visitors to EDs with a higher proportion of low-income and poorly insured patients experienced a higher risk of left without being seen. We found that the odds of an ED visit resulting in left without being seen increased by a factor of 1.15 for each 10-percentage-point increase in poorly insured patients, and odds of left without being seen decreased by a factor of 0.86 for each $10,000 increase in household income. When hospital structural characteristics were added to the model, county ownership, trauma center designation, and teaching program affiliation were positively associated with increased probability of left without being seen (odds ratio 2.09; 1.62, and 2.14, respectively), and these factors attenuated the association with insurance status. CONCLUSION: Visitors to different EDs experience a large variation in their probability of left without being seen, and visitors to hospitals serving a high proportion of low-income and poorly insured patients are at disproportionately higher risk of leaving without being seen. Our findings suggest that there is room for substantial improvement in this outcome, and regional interventions can be targeted toward certain at-risk hospitals to improve access to emergency care.

PMID: 21334761 [PubMed - as supplied by publisher]